A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?
A) Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.
B) Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints.
C) Breathing without difficulty. Sitting up in bed watching TV. Had a good day.
D) Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

Question

Quizplus · Accepted Answer

Accurately documenting services provided, including the supplies and equipment used in a patient's care, clarifies the type of treatment a patient received. This documentation also supports accurate and timely reimbursement to a health care agency and/or patient. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as "status unchanged" or "had good day." Do not enter personal opinions-stating that the patient is cooperative is a personal opinion and should be avoided. "Finally, patient had no complaints" is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care.

A Patient Has a Diagnosis of Pneumonia